Ocular Rosacea by Sandra Cremers, MD


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Ocular Rosacea by Sandra Cremers, MD

  1. 1. A Hidden Concern in Ocular RosaceaSandra Lora Cremers, MD, FACS March 2013
  2. 2. THUMP!
  3. 3. Rosacea, Boring and Not Glamorous?
  4. 4. Objectives:1. Describe Epidemiology, Diagnosis,Pathophysiology, and Treatment ofRosacea and Ocular Rosacea2. Discuss Recent Research Finding ofRosacea and Ocular Rosacea3. Discuss Ocular Rosaceas Relationshipto other Angiogenesis Based Diseases
  5. 5. Outline:1. Case Presentations2. Diagnosis and Details3. Observations & Collaborations4. A Hidden Concern
  6. 6. 1. Case Presentations
  7. 7. Case Presentation:79 yo white male presents complainingof "poor vision in right eye after cataract surgery. Worse than before the surgery"
  8. 8. Case Presentation:BCVA: 20/50 OD, 20/30 OSExternal exam:
  9. 9. R
  10. 10. Ultimate Diagnosis: Unhappy patient because he perceived a missed diagnosis ofocular rosacea as the reason for less than expected vision after cataract surgery.
  11. 11. A Brief Historical Perspective
  12. 12. Young Rembrandt Older Rembrandt
  13. 13. 2. Diagnosis and Details
  14. 14. A Definition of RosaceaRosacea is a multifactorial, hyper-reactivity, vascular andneural based disease with a broad range of facial andmanifestations where normal vasodilation is greater andmore persistent and involves an autoimmune componentwhere microscopic amounts of extravasated plasma inducelocalized dermal inflammation where repeated externaltriggers lead vasodilation, telangiectasias, redness witheventual fibrosis and hypertrophic scarring of the dermis.
  15. 15. Subtypes ofROSACEA
  16. 16. What is Ocular Rosacea and How do you make the Diagnosis?
  17. 17. Epidemiology of Ocular Rosacea:1. In 3-58% of patients with Rosacea2. M=F3. European descent more common4. Starts in 20s and often worsens with age5. Can be seen in kids
  18. 18. Symptoms:1. Burning2. Foreign body sensation3. Dry eye4. Tearing (reflex)5. Eye redness6. Mattering of eyelids
  19. 19. Signs:1. Blepharitis & MGD2. Lid margin telangiectasia3. Conjunctivitis4. Recurrent chalazia5. Corneal pannus6. SPK7. Episcleritis, Scleritis (not common)8. Interstitial keratitis & residual cornealscarring
  20. 20. Signs:1. Blepharitis & MGD2. Lid margin telangiectasia3. Conjunctivitis4. Recurrent chalazia5. Corneal pannus6. SPK7. Episcleritis, Scleritis (not common)8. Interstitial keratitis & residual corneal scarring
  21. 21. Pathophysiology
  22. 22. Many Theories of Ocular RosaceaIngested Agents Climatic Exposures Vascular Pilosebaceous anomalies Matrix Degeneration Chemicals Microbial Demodex Bacillus oleronius
  23. 23. Many Theories of Ocular Rosacea● Demodex folliculorum mites: Bacillus oleronius bacteria within● Increased sulfated O-glycans in tear film
  24. 24. DEMODEX
  25. 25. Complications of Ocular Rosacea1. Chronic Dry Eye2. Corneal Vascularization3. 2nd Bacterial Infections4. Perforation5. Increased graft failure after PK
  26. 26. Complications of Ocular RosaceaIncreased Graft Rejection in PK patients
  27. 27. Treatments
  28. 28. Usual Treatments of Ocular Rosacea 1. Lid hygiene: Warm Compresses Baby shampoo scrubs 2. Artificial tears, nonpreserved 3. Antibiotics po: doxycycline, tetracycline, clarithromycin, metronidazole; Erythromycin for kids 4. Erythromycin ointment 5. Topical steroids 6. Restasis: Topical cyclosporine A b.i.d. x 3 mo
  29. 29. Newer Ocular Rosacea Treatments:1. Intense Pulse Light Therapy (IPL)3. LipiFlow4. Intraductal MG Probing, Maskin
  30. 30. Doxycycline Risks:
  31. 31. Prevention
  32. 32. Usual Prevention:● Avoid foods, drinks, and situations that trigger outbreaks like sun● Hat, sunglasses● increase Omega 3s intake
  33. 33. Subtypes ofROSACEA
  34. 34. 4. A Hidden Concern
  35. 35. Years of Observations of Ocular Rosacea 1. If also had diabetes, tended to develop proliferative diabetic retinopathy 2. If they also had age related macular degeneration (ARMD), tended to develop wet ARMD 3. If they had a corneal transplant, they would tend to have a rejection more often.
  36. 36. A Chance Encounter at Grand Rounds
  37. 37. Who is this man?
  38. 38. Nature. 2009 Jun 25;459(7250):1126-30. doi: 10.1038/nature08062.
  39. 39. Sandra Lora Cremers, MD, FACSHarvard Medical SchoolGrant: National Rosacea Society
  40. 40. Results: Patient 3, CD 31+
  41. 41. Results: Patient 1, CD31+
  42. 42. Results: Patient 1, VEGF+
  43. 43. Doxycycline Magical Properties:1. Anti-Angiogenic at low doses2. Anti-bacterial at higher doses
  44. 44. Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS NGF Neuronal-Driven Angiogenesis PDGFGrants: Harvards 50th Anniversary ScholarsGrant; National Rosacea Society; Lions Eye
  45. 45. Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS Low Oxygen state NGF Neuronal-Driven Angiogenesis PDGF low dose 0.5 mg/kg/d - significantly reduces BV growth & Doxy migrationmitochondrial genes,ER stress cascade,growth factors,interleukins, nitric oxide (NO) synthetasecell cycle regulators,integrins, and componentsof the extracellular matrix;TNF-alpha, IL-10 and Grant provided by National Rosacea SocietyIFNgamma
  46. 46. More Complete Definition of RosaceaRosacea is a multifactorial, hyper-reactivity, vascular andneural based disease with a broad range of facial andocular manifestations where normal vasodilation is greaterand more persistent and involves an autoimmunecomponent where microscopic amounts of extravasatedplasma induce localized dermal and meibomian glandinflammation and where repeated external triggers lead toangiogenesis (the recruitment of new blood vessels),vasodilation, teleangiectasias, redness with eventualfibrosis and hypertrophic scarring of the dermis andmeibomian glands.Likely a central underlying factor in all subtypes of rosacea,particularly ocular rosacea, involves VEGF and similarangiogenic factors.
  47. 47. Future Research For Ocular Rosacea 1. Is Severe Ocular Rosacea due to increased angiogenesis activity at the lid margin? 2. Would they benefit from topical anti- angiogenic medications?
  48. 48. Future Research For Ocular Rosacea 1. Do severe ocular rosacea patients have an increased risk of systemic angiogenesis? 2. Do these patients need to be evaluated for an increased risk of internal tumors or metastasis if primary tumors present?
  49. 49. Recommendations for Ocular Rosacea Patients:1. Avoid inflammatory factors (triggers, sun, smoke)2. Eat antioxidants, Omega 3s,2. If must treat with doxycycline, use lowest doseStart with 20mg q day; 40-mg, controlled release formulationof doxycycline monohydrate is an anti-inflammatory drug3. General medical check ups
  50. 50. Thank you for your attention.
  51. 51. References:1. Rohrich RJ, Griffin JR, Adams WP., Jr Rhinophyma: Review and update. Plast Reconstr Surg.2002;110(3):860–869. quiz,870.2. Scheinfeld NS. Rosacea. Skinmed. 2006;5:191–194.3. Glycomic analysis of tear and saliva in ocular rosacea patients: the search for abiomarker. Ocul Surf. 2012 Jul;10(3):184-92 , Vieira AC, An HJ, Ozcan S, Kim JH,Lebrilla CB, Mannis MJ.2. http://rosacea-support.org/ocular-rosacea-diagnostic-test-one-step-closer.html3.4. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commerciallyavailable topical cyclosporine A 0.05%in the treatment of meibomian gland dysfunction. Cornea. 2006;25:171-1753. Stone, Curr Opin Ophthalmol, 2004http://www.rosacea-treatment.org/6. http://videos.med.wisc.edu/videos/375717. Doxycyclines Effect on Ocular Angiogenesis: an In Vivo Analysis.Ophthalmology 2010 Sept, 117(9): 1782-1791. Cox, C, et al.8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315879/9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-
  52. 52. References continued:9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-controlled, parallelgroup trial results evaluating the effects of 40 mgdoxycycline monohydrate controlled-release capsules in the treatment of rosacea.Poster presented at: 64 th American Academy of Dermatology Meeting ; March3–7, 2006; San Francisco, Calif.10.http://www.globalacademycme.com/fileadmin/pdf/supplement_pdf/fczjw6vm_sanews_supplement46.pdf